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Praktijkleren 3: Klinisch redeneren- Cijfer 8,4!
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  • Course
  • Praktijkleren 3 (GVE3.PL316)
  • Institution
  • Hogeschool Utrecht (HU)
  • Book
  • Klinisch redeneren bij ouderen

Opdracht Klinisch redeneren t.b.v. een veranderde situatie, onderdeel van het portfolio gedurende praktijkleren 3. Het verslag is op 20 juni 2023 beoordeeld met een 8,4! De stageopdracht klinisch redeneren is terug te vinden in dit verslag. De casus is uit het ziekenhuis. In de bijlagen is het fe...

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Document information

  • June 29, 2023
  • 36
  • 2022/2023
  • Case
  • Bakker et al. (2019)
  • 8-9

Subjects

  • pl3
  • praktijkleren 3
  • klinisch redeneren
  • portfolio
  • apa
  • hbo v
  • gve 3pl3 16
  • hogeschool utrecht

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Written for

  • Hogeschool Utrecht (HU)
  • Verpleegkunde
  • Praktijkleren 3 (GVE3.PL316)
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Klinisch redeneren
Praktijkleren 3




Naam:
Studentnummer:
Mailadres:
Groepscode:
Toets code: GVE-3.PL3-16
Examinator:
Inleverdatum: 19-06-2023
Versie: Eerste poging
Aantal woorden: 4478

,Inhoudsopgave
Inleiding ................................................................................................................................................... 5
Klinisch redeneren..........................................................................................................................
1 Probleemoriëntatie/klinisch beeld .................................................................................................. 6
1.1 Introductie patiënt .................................................................................................................. 6
1.2 De veranderde situatie ............................................................................................................ 6
1.2.1 Delirium Observatie Screening (DOS) Schaal .................................................................. 6
1.2.2 Ernst van de situatie ........................................................................................................ 7
1.2.3 Relevante context............................................................................................................ 7
1.3 Differentiaal diagnose ............................................................................................................. 8
2 Probleemanalyse ............................................................................................................................. 9
2.1 Disfunctionele orgaansystemen .............................................................................................. 9
2.1.1 Neurologisch systeem ..................................................................................................... 9
2.1.2 Vocht- en elektrolytenbalans .......................................................................................... 9
2.1.3 Endocrien systeem .......................................................................................................... 9
2.2.4 Afweersysteem ................................................................................................................ 9
2.2 Psychische stoornis................................................................................................................ 10
2.3 Psychosociale problematiek .................................................................................................. 10
2.4 Functionele problematiek ..................................................................................................... 10
2.5 Spirituele problematiek ......................................................................................................... 10
2.6 Analyse van de resultaten ..................................................................................................... 10
3 Aanvullend onderzoek en diagnose .............................................................................................. 11
3.1 Aanvullende anamnese en familieparticipatie ...................................................................... 11
3.2 Delier-O-meter ...................................................................................................................... 11
3.3 Glasgow Coma Scale .............................................................................................................. 11
3.4 Controle van de vitale functies .............................................................................................. 11
3.5 Signaleren van pijn ................................................................................................................ 11
3.6 Aanvullende onderzoeken..................................................................................................... 11
3.6 Medische diagnose ................................................................................................................ 12
3.7 Verpleegkundige diagnoses................................................................................................... 12
4 Klinisch beleid ................................................................................................................................ 13
4.1 Prioritering verpleegkundig handelen ................................................................................... 15
4.2 Gezamenlijke besluitvorming ................................................................................................ 15
5 Klinisch verloop ............................................................................................................................. 16
5.1 Verloop op korte en lange termijn ........................................................................................ 16


3

, 5.2 Gevolgen op somatisch, psychisch en (psycho)sociaal functioneren ................................... 16
5.3 Nazorg ................................................................................................................................... 17
6 Evaluatie ........................................................................................................................................ 18
6.1 Evaluatie doelen .................................................................................................................... 18
6.2 Reflectie zorgproces .............................................................................................................. 18
6.3 Reflectie elektronisch patiëntendossier (EPD) ...................................................................... 18
Literatuurlijst ......................................................................................................................................... 19
Bijlagen .................................................................................................................................................. 21
Bijlage 1: Verpleegkundige anamnese .............................................................................................. 21
Bijlage 2: Verschil tussen delier en dementie ................................................................................... 23
Bijlage 3: Ingevulde DOS 17 maart .................................................................................................... 24
Bijlage 4: Medicatieoverzicht ............................................................................................................ 25
Bijlage 5: Modified Early Warning Scores (MEWS) ........................................................................... 26
Bijlage 6: Heteroanamnese vragenlijst.............................................................................................. 27
Bijlage 7: Delier-O-meter................................................................................................................... 30
Bijlage 8: Ingevulde PAINAD .............................................................................................................. 32
Bijlage 9: Toelichting labuitslagen ..................................................................................................... 33
Bijlage 10: Feedbackformulier klinisch redeneren ............................................................................ 36




4

, Inleiding
In het derde jaar van de opleiding tot hbo-verpleegkundige start het praktijkleren 3 waarin er wordt
stage gelopen. Gedurende praktijkleren 3 worden er een aantal stageopdrachten gemaakt,
waaronder klinisch redeneren en onderzoekend vermogen (Critical Appraisal of a Topic). De
stageopdracht klinisch redeneren is terug te vinden in dit verslag. In de bijlagen is het
feedbackformulier over de opdracht toegevoegd die is ingevuld door de werkbegeleider.




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